DOI:http://dx.doi.org/10.7314/APJCP.2013.14.6.

3979
Epidemiology of Primary CNS Tumors in Iran: A Systematic Review

RESEARCH ARTICLE

Epidemiology of Primary CNS Tumors in Iran: A Systematic

Review
Seyed Behzad Jazayeri1,2, Vafa Rahimi-Movaghar1,3*, Farhad Shokraneh4, Soheil
Saadat1, Rashid Ramezani5
Abstract
Background: Although primary malignant CNS tumors are registered in the national cancer registry (NCR)
of Iran, there are no available data on the incidence of the primary malignant or benign CNS tumors and their
common histopathologies in the country. This study analyzed the 10-year data of the Iranian NCR from March
21, 2000 to March 20, 2010, including a systematic review. Materials and Methods: The international and national
scientific databases were searched using the search keywords CNS, tumor, malignancy, brain, spine, neoplasm
and Iran. Results: Of the 1,086 primary results, 9 papers were selected and reviewed, along with analysis of
10-year NCR data. The results showed that primary malignant brain tumors have an overall incidence of 2.74
per 100,000 person-years. The analysis of the papers revealed a benign to malignant ratio of 1.07. The most
common histopathologies are meningioma, astrocytoma, glioblastoma and ependymoma. These tumors are more
common in men (M/F=1.48). Primary malignant spinal cord tumors constitute 7.1% of the primary malignant
CNS tumors with incidence of 0.21/100,000. Conclusions: This study shows that CNS tumors in Iran are in
compliance with the pattern of CNS tumors in developing countries. The NCR must include benign lesions to
understand the definitive epidemiology of primary CNS tumors in Iran.
Keywords: Benign - malignant - tumor - CNS - epidemiology - incidence - Iran

Asian Pacific J Cancer Prev, 14 (6), 3979-3985

Introduction such registries has been published in the US, Canada,

The incidence of primary CNS Tumors has been
estimated as 3.9 and 3.2 per 100,000 person-year
worldwide in males and females, respectively (Ferlay et
al., 2010). However, the reported incidence of primary
CNS tumors is higher in developed countries (Bondy et al.,
2008). Nevertheless, the incidence of primary malignant
CNS tumors ranges from 2.1 to 5.8 per 100,000 population
in the world (Bondy et al., 2008).
The reported incidence of primary CNS tumors has
increased from 11.5 in 1994 to 20.1in 2008 per 100,000
persons in the US (Surawicz et al., 1999; Bondy et al.,
2008). The incidences of brain and spinal cord tumors in
USA are 19.5 and 0.6 per 100,000 individuals, respectively.
The importance of descriptive data on the full spectrum of
primary brain and spinal cord tumors is mainly for its role
of assessing risk factors, finding at-risk populations and as
a rich database for studying relatively rare brain tumors
(Kurland et al., 1982; Deorah et al., 2006). For the first
time, a CNS tumor registry was begun in 1902 by Harvey
Cushing (Wahl et al., 2009) and subsequently the registry
expanded to other countries. The epidemiologic data from
France, Denmark, Norway, Finland, Sweden, Australia,
India, Korea and Japan (Davis et al., 1999; Kaneko et al.,
2002; Bauchet et al., 2007; Pirouzmand and Sadanand,
2007; Deltour et al., 2009; Lee et al., 2010; Baldi et al.,
2011; Dobes et al., 2011; Manoharan et al., 2012).
A local cancer registry in Iran began in 1955 with
the establishment of Cancer Institute at the University
of Tehran (Etemadi et al., 2008). The first formal cancer
related data from Iran were published by Habibi in 1962
(Habibi, 1962; Listed, 1977). The late professor Ameli
(Ameli et al., 1979; Alimi and Rahimi-Movaghar, 2012)
and Ardehali (1990) published the first reports on the
brain and spinal cord tumors in Iran in 1979 and 1990,
respectively. Since 1984, all pathology centers in Iran are
required to (by law from parliament) report all tissues
“diagnosed or suspected of cancer/malignant” to the
Ministry of Health. Malignant cases are reported according
to International Classification of Diseases-Oncology
(ICD-O). After the foundation of the National Cancer
Registry (NCR) module, several reports for incidence and
prevalence of malignancies were published from single
centers and/or different provinces/cities of the country

1
Sina Trauma and Research Center, 2Students’ Scientific Research Center, Tehran University of Medical Sciences, 4Research Center
for Pharmaceutical Nanotechnology and Iranian Center for EBM, Tabriz University of Medical Sciences, 3Research Center for
Neural Repair, University of Tehran, 5Ministry of Health, Center for Disease Control and Prevention, Non-communicable Diseases
Unit, Cancer Office, Tehran, Iran *For correspondence: v_rahimi@sina.tums.ac.ir, v_rahimi@yahoo.com
Asian Pacific Journal of Cancer Prevention, Vol 14, 2013 3979
Seyed Behzad Jazayeri et al
(Larijani et al., 2004; Babaei et al., 2005; Mohagheghi
et al., 2009; Mousavi et al., 2009). There are no accurate
published nationwide CNS tumor epidemiology data for
Iran, and this makes policy making for prevention, tumor
screening and treatment modalities difficult.
This study attempts to report a systematic review of
the epidemiology of CNS tumors in Iran, in published
and recently unpublished reports of NCR data, and in all
available published data from authors in English and Farsi
journals, and estimates the incidence of primary benign
and malignant brain and spinal cord tumors and their
common pathologies.
Materials and Methods
This systematic review was designed in accordance
with the PRISMA group guideline of systematic review
requirements (Moher et al., 2010). Keywords were
selected under the supervision of a neurosurgeon and a
medical librarian who designed the appropriate search
strategy for each database (Table 1). On April 17th
2012, Medline, Embase, ISI web of knowledge and
Google scholar for international papers and three Iranian
databases of Scientific Information Database (SID)
(http://www.sid.ir), MagIran (www.magiran.com), and
Table 1. Search Strategy of Systematic Review of
Epidemiology of CNS Tumors in Iran
Medline via Ovid SP
1. exp central nervous system/
2. exp skull/
3. (central nervous system).tw,ot.
4. (skull or crani?).tw,ot.
5. (brain? or intracrani? or cerebroventricular or intraventricular
or cerebr? or (choroid plexus) or infratentorial or (posterior
fossa) or pontine or mesencephalic or midbrain or medullary or
cerebell? or supratentorial or hypothalam? or pituitary or pineal).
tw,ot.
6. meninge?.tw,ot.
7. ((spinal cord) or epidural).tw,ot.
8. or/1-7
9. exp neoplasms/
10. (neoplas? or tumor? or cancer? or benign or malignan? or
metasta?).tw,ot.
11. (adenoma? or carcino?).tw,ot.
12. or/9-11
13. 8 and 12
14. central nervous system neoplasms/
15. brain neoplasms/
16. meningeal neoplasms/
17. spinal cord neoplasms/
18. (neurocytoma? or pinealoma? or pineoblastoma? or
pinealocytoma? or pineocytoma?).tw,ot.
19. ((somatotroph? or corticotroph? or lactotroph?) adj adenoma?).
tw,ot.
20. (prolactinoma? or microprolactinoma? or macroprolactinoma?).
tw,ot.
21. meningioma.tw,ot.
22. (leptomeningeal adj (neoplas? or tumo?r? or cancer? or benign
or malignan? or metasta?)).tw,ot.
23. or/13-22
24. iran/
25. (iran? or persia?).tw,ot,af.
26. or/24-25
27. 23 and 26
28. Limit 27 to animals
29. Limit 27 to humans
3980 Asian Pacific Journal of Cancer Prevention, Vol 14, 2013
IranMedex (www.iranmedex.com) for Farsi articles were
searched. Keywords included: central nervous system,
brain, intracranial, cerebroventricular, intraventricular,
cerebrum, choroid plexus, infratentorial, posterior fossa,
pontine, mesencephalic, midbrain, medullary, cerebellum,
supratentorial, hypothalamus, pituitary, neoplasm,
cancer, malignancy and Iran. Results were integrated
into an EndNote X5 library and duplicates were then
automatically removed. Two independent reviewers
(VRM and SBJ) reviewed the remaining papers. We used
ten-year (March 21, 2000- March 20, 2010) raw data of
NCR (2000-2009) and percent of coverage of registered
primary malignant tumors in 10 years to estimate the
incidence of primary malignant brain and spinal cord
tumors and their different pathologies.
During the ten years of the registry program, the
coverage of 20% in 2000 has progressed to 93% in 2009.
To estimate the incidence of common primary malignant
brain and spinal cord tumors, we used the accurate data
from the last verified year (from March 21, 2009 to March
20, 2010). In this study, metastatic tumors were excluded.
Since papers have reported the total count of astrocytoma
and glioblastoma together as gliomas, data of glioma were
not included in the analysis. NCR data did not include
the primary benign tumors of the brain and spinal cord.
Therefore, we used data from all available comprehensive
single center published papers for primary brain and spinal
cord tumors. The ratio of benign to malignant tumors
were calculated based on these reports and was used to
estimate the incidence of benign tumors in the country.
The same process was used for sex and age distributions
of the tumors.
Results
Primary searches found 1086 entities in addition to
the database of NCR data. Of the primary results, 562
duplicates were removed, and this limited resources to 524
papers. One hundred thirty four papers were then selected
based on their relevance to the subject after reading titles
and abstracts. Of the initial 134 selected articles, 36 papers
were removed because the report was limited to specific
tumor types or specific treatment methods, 17 papers
were deleted because the reports were limited to data of
a specific age groups, 22 papers were reporting the same
data of the NCR along with 6 case reports, 17 papers
which had no epidemiologic data and 27 papers were
rejected following quality control. Therefore, the 10-years
data of NCR (2000-2009) and nine papers (Ameli et al.,
1979; Ketabchi and Ghodsi, 1989; Ardehali, 1990; Rezaee
and Hadadian, 1997; Meshkini et al., 2000; Mahzoni
and Mohammadizadeh, 2003; Reyhani-Kermani, 2003;
Mehrazin et al., 2006; Seddighi et al., 2010) related to the
CNS tumors were selected (Figure 1). These nine CNS
papers consisted of seven papers for brain (Ameli et al.,
1979; Ketabchi and Ghodsi, 1989; Meshkini et al., 2000;
Mahzoni and Mohammadizadeh, 2003; Reyhani-Kermani,
2003; Mehrazin et al., 2006; Seddighi et al., 2010) and
two papers for spinal cord tumors (Ardehali, 1990; Rezaee
and Hadadian, 1997).
The NCR reports have been published regularly in
 DOI:http://dx.doi.org/10.7314/APJCP.2013.14.6.3979
Epidemiology of Primary CNS Tumors in Iran: A Systematic Review
Farsi since 2000-2009 and while in its first year, only Table 2. Primary Malignant Brain Tumors in Iran
20% of the estimated cancer cases were reported; this Registered in the NCR Database
rate has increased to 93% in 2009. Primary malignant Year Brain Tumors All organ sites Coverage
CNS tumors in Iran encompass 2.3% (95%CI: 2.3-2.4) Male Female Total
of all primary malignant tumors (Table 2). A total of
2000 161 94 255 (1.93) 13240 20%
10,868 cases of primary malignant brain tumors were
2001 140 87 227(1.66) 13703 20%
registered between 2000 and 2009. In the rechecking the 2002 277 185 462(1.76) 26248 41%
details of the entered data, 66 cases were found to have 2003 543 333 876(2.28) 38468 60%
incompatible site and histologic coding values in the raw 2004 668 428 1096(2.32) 47217 70%
data; these cases were removed from the study, hence, 2005 712 450 1162(2.08) 55855 81%
10,802 cases are shown (Table 3). Histologic confirmation 2006 793 544 1337(2.24) 59786 83%
was achieved in 94.7% (10,227/10,802) of the cases. 2007 862 624 1486(2.39) 62040 87% 100.0
Astrocytoma and glioblastoma together form 60.4% of 2008 1183 785 1968(2.66) 74076 93%
6.
the primary malignant registered brain tumors in Iran 2009 1150 849 1999(2.70) 74068 -
(Table 4). Astrocytoma is the most common pathology of Total 6489 4379 10,868(2.34) 464,701
75.0
the registered tumors, except in 2000 where glioblastoma
Table 3. Summary of Registered Brain Tumors between
is registered as the most common type. Astrocytoma and
2000 and 2009 by Sex and Histology in Iran 56
glioblastoma are both more common in males (M/F=1.5
and 1.8, respectively). The incidence of primary malignant Histology
ICD-O Male Female Total Relative 50.0
frequency (%)
CNS tumors was 2.73 per 100,000 for primary malignant
Neoplasm malignant 8000 308 267 575 5.32
Tumor cells, malignant 8001 6 3 9 0.08
Malignant tumor, small cell type 8002 35 20 55 0.51 25.0
Malignant tumor, giant cell type 8003 1 0 1 0.01
Malignant tumor, spindle cell type 8004 0 1 1 0.01 31
Malignant melanoma, NOS 8720 2 1 3 0.03
Sarcoma, NOS 8800 3 1 4 0.04
0
Spindle cell sarcoma 8801 0 1 1 0.01
Small cell sarcoma 8803 1 0 1 0.01 100.0
Desmoplastic small round cell 8806 2 0 2 0.02
Fibrosarcoma, NOS 8810 0 1 1 0.01 6.
Liposarcoma 8851 0 1 1 0.01
Embryonal rhabdomyosarcoma 8910 1 0 1 0.01
Germinoma 9064 16 17 33 0.31 75.0
Teratoma, malignant 9080 1 1 2 0.02
Mixed germ cell tumor 9085 2 1 3 0.03 56
Hemangioendothelioma, malignant 9130 0 1 1 0.01
Hemangiopericytoma, malignant 9150 5 4 9 0.08 50.0
Hemangioblastoma 9161 0 1 1 0.01
Pineoblastoma 9362 1 0 1 0.01
Chordoma 9370 3 2 5 0.05
Glioma, malignant 9380 51 31 82 0.76 25.0
Gliomatosis cerebri 9381 2 0 2 0.02
Mixed glioma 9382 137 111 248 2.30 31
Subependymal giant cell astrocytoma
9384 1 0 1 0.01
Choroid plexus papilloma, malignant 0
9390 8 15 23 0.21
Ependymoma, NOS 9391 188 133 321 2.97
Figure 1. The Algorithm of Paper and Resource
  Ependymoma, anaplastic 9392 44 32 76 0.70
Selection
Table 4. Number and Relative Frequency of Five Major Primary Malignant Brain Tumors from 2000 to 2009
in Iran
Year Astrocytoma Glioblastoma Oligodendroglioma Medulloblastoma Ependymoma Others Total
2000 70 (27.6) 98 (38.6) 21 (8.3) 17 (6.7) 6 (2.4) 42 (16.5) 254 (100)
2001 71 (32.6) 72 (33.0) 8 (3.7) 16 (7.3) 9 (4.1) 42 (19.3) 218 (100)
2002 149 (33.3) 119 (26.6) 28 (6.3) 31 (6.9) 17 (3.8) 104 (23.2) 448 (100)
2003 315 (36.0) 240 (27.4) 49 (5.6) 52 (5.9) 32 (3.7) 187 (21.4) 875 (100)
2004 381 (34.8) 324 (29.6) 67 (6.1) 42 (3.8) 33 (3.0) 249 (22.7) 1096 (100)
2005 426 (36.7) 342 (29.5) 76 (6.5) 67 (5.8) 50 (4.3) 200 (17.2) 1161 (100)
2006 459 (34.4) 371 (27.8) 85 (6.4) 96 (7.2) 47 (3.5) 277 (20.7) 1335 (100)
2007 449 (30.5) 444 (30.2) 85 (5.8) 79 (5.4) 59 (4.0) 354 (24.1) 1470 (100)
2008 553 (28.4) 535 (27.5) 124 (6.4) 91 (4.7) 68 (3.5) 576 (29.6) 1947 (100)
2009 555 (27.8) 556 (27.8) 135 (6.8) 85 (4.3) 76 (3.8) 591 (29.6) 1998 (100)
Total 3428 (31.7) 3101 (28.7) 678 (6.3) 576 (5.3) 397 (3.7) 2622 (24.3) 10802 (100)
* (15.2) (13.8) (3) (2.5) (1.8)
*Percentage of different primary malignant brain tumors in all primary benign and malignant brain tumors

Asian Pacific Journal of Cancer Prevention, Vol 14, 2013 3981

Seyed Behzad Jazayeri et al
brain tumors (Table 5), which comprises incidence rates
of 3.10 and 2.37 for males and females, respectively.
Benign brain tumors are not registered in NCR data.
A summary of published data is shown in Table 6. Benign
CNS tumors range from 30.3% (Seddighi et al., 2010) to
58.2% of all CNS tumors indifferent studies (Meshkini
et al., 2000). In the analyzes of the seven available
studies, benign tumors composed 51.9% of all primary
brain tumors. Meningioma (27.8%), pituitary adenoma
(11.3%) and schwannoma (5.9%) are the most common
pathologies in benign brain tumors (Table 6). The gender
distribution of benign brain tumors was reported in three
papers, (Meshkini et al., 2000; Reyhani-Kermani, 2003;
Mehrazin et al., 2006) which were analyzed to determine
the sex distribution of benign tumors in Iran. Although
brain tumors are generally more common in males,
meningioma was more common in females (M/F: 0.69).
The mean age and incidence of the most common
pathologies of primary brain tumors are shown in Table
7. Analysis of NCR data and published evidence revealed
incidence of 2.95 per 100,000 persons for primary benign
brain tumors. Three papers have reported the total count of
Table 5. Age Specific Rate (ASR) of Malignant Brain
Tumors in Iran (2009)
No. ASR
Age group 0-4 99 1.67
5-9 68 1.21
10-14 71 1.17
15-19 81 1.09
20-24 115 1.33
25-29 143 1.77
30-34 175 2.73
35-39 180 3.39
40-44 156 3.41
45-49 162 4.23
50-54 165 5.13
55-59 149 6.3
60-64 148 8.69
65-69 114 8.87
70-74 78 6.97
74-79 52 6.3
80+ 43 5.31
Overall 1999 2.73
astrocytoma and glioblastoma together as gliomas: these
data were not included in the analysis (Ameli et al., 1979;
Mahzoni and Mohammadizadeh, 2003; Reyhani-Kermani,
2003). Meningioma as the most common pathology of
benign brain tumors has incidence of 1.58 per 100,000
person-years.
Primary malignant spinal cord tumors registered in
the NCR are shown in Table 7. In the rechecking process
for spinal cord registered tumors, 21 cases were excluded
because of coding miss-match. Primary malignant spinal
cord tumors composed 7.1% of primary malignant
brain tumors which has incidence of 0.21 per 100,000.
Malignant neoplasm composes 34.4% of all malignant
spinal cord tumors in the NCR data. Primary malignant
spinal cord tumors are more common in males, with a male
to female ratio of 1.26. A total of 767 cases of primary
malignant spinal cord tumors were registered between
2000 and 2009 (Table 8). Published papers of spinal
cord tumors in Iran are limited to two studies, (Ardehali,
1990; Rezaee and Hadadian, 1997) which reported
the most common pathologies as nerve sheath tumors,
meningioma and neuroepithelial tumors (Table 9). Nerve
sheath tumors and meningioma together formed 56.4% of
primary spinal cord tumors. Therefore, the incidence of
these two benign tumors is 0.27 per 100,000. The total
primary spinal cord tumors are estimated to be 0.48 per
100,000.Three common pathologies of spinal cord tumors
consist of neurofibroma (30.7%), meningioma (25.7%),
and malignant neoplasm (15.0%).
Table 7. Incidence Rate and the Mean Age of Patients
of Common Pathologies of Malignant Brain Tumors
in Iran Based on NCR Data
Age at diagnosis Incidence
per 100,000
(Mean± SD) (CI 95%)
Female Male Overall Overall
Astrocytoma 36.1±17.6 38.0±17.7 37.2±17.7 0.76 (0.70-0.83)
Ependymoma 25.7±17.7 25.7±19.0 25.7±18.4 0.10 (0.08-0.13)
Glioblastoma 50.3±17.0 50.8±16.9 50.6±16.9 0.76 (0.70-0.83)
Medulloblastoma 15.8±12.3 15.6±12.4 15.7±12.4 0.12 (0.09-0.14)
Oligodendroglioma 39.3±14.6 40.0±14.8 39.7±14.6 0.19 (0.16-0.22)
Malignant brain tumors
39.5±19.8 40.7±19.7 40.2±19.8 2.74 (2.62-2.86)

Table 6. Relative Frequency of Brain Tumors in Published Papers of Iran

Mehrazin Ketabchi Ameli Meshkini Mahzoni Reyhani- Seddighi Total
Kermani
et al et al et al et al et al et al et al
(1978-2003) (1977-1986) (1949-1978) (1997-2006) (1996-2000) (1997-2001) (2007-2009)
Astrocytoma 747(23.7) 328(13.3) 460(30.7) 158 (13) 135(33.8) 119(35.2) 20 (22.5) 1253/6792 (18.4)
Glioblastoma 162 (5.1) 226 (9.2) 203(16.6) 27 (30.3) 618/6792 (9.0)
Oligodendroglioma 26 (0.8) 48 (1.9) 46 (3.1) 28 (2.4) 26 (6.5) 16 (4.7) - 190/8961* (2.1)
Ependymoma 143 (4.5) 93 (3.8) 55 (3.7) 54 (4.5) 4 (1) 20 (5.9) 4 (4.5) 373/8961 (4.1)
Medulloblastoma 145 (4.6) 99 (4) 71 (4.7) 5 (0.5) 5 (1.3) - 3 (3.4) 328/8961 (3.7)
Meningioma 821(26.0) 591(23.9) 435 (29) 353 (29) 184 (46) 97(28.7) 15(16.9) 2496/8961 (27.8)
Pituitary adenoma 448(14.2) 257(10.4) 91 (6.1) 206 (17) - - 8 (9) 1010/8961 (11.3)
Schwannoma 255 (8.1) 150 (6.1) - 86 (7) 28 (7) 16 (4.7) - 535/8961 (5.9)
Congenital tumors - 178 (7.2) 23 (1.5) - - 15 (4.4) - 216/8961 (2.4)
Metastasis - 94 (3.8) 48 (3.2) 40 (3.3) - 21 (6.3) 5 (5.5) 207/8961 (2.3)
Others 406(12.9) 405(16.4) 271(18.1) 82 (6.7) 18 (4.5) 34 (10) 8 (8.9) 1224/8961 (13.6)
Total 3153 (100) 2469 (100) 1500 (100) 1220(100) 400(100) 338 (100) 89 (100) 9169
*Metastases are excluded from the total number. Parenthesis shows the percentage

3982 Asian Pacific Journal of Cancer Prevention, Vol 14, 2013

 DOI:http://dx.doi.org/10.7314/APJCP.2013.14.6.3979
Epidemiology of Primary CNS Tumors in Iran: A Systematic Review
Table 8. Primary Malignant Spinal Cord Tumors benign and malignant brain tumors are estimated to be
Registered between 2000 and 2009 in Iran 2.95 and 2.74 per 100,000, respectively. Percentages of
Morphology ICD-O Male Female Total Relative common brain tumor histopathologies are Meningioma
frequency (27.8%), Astrocytoma (15.2%), Glioblastoma (13.8%),
(%) Pituitary adenoma (11.3%), Schwannoma (5.9%)
Neoplasm malignant 8000 137 127 264 34.4 Oligodendroglioma (3.0%), Medulloblastoma (2.5%) and
Malignant tumor, small cell type 8002 38 28 66 8.6 Ependymoma (1.8%). The incidence of primary spinal
Malignant tumor, spindle cell type
cord tumors in Iran is estimated to be 0.48 per 100,000;
8004 3 1 4 0.52
Sarcoma, NOS 8800 1 0 1 0.13 benign and malignant spinal cord tumors are estimated to
Spindle cell sarcoma 8801 1 1 2 0.26 be 0.27 and 0.21 per 100,000, respectively. Percentages
Small cell sarcoma 8803 1 0 1 0.13 of common spinal cord tumor histopathologies are
Desmoplastic small round cell tumor 100.0
100.0Neurofibroma (30.7%), Meningioma (25.7%), and
100.0
8806 0 1 1 0.13
Germinoma 9064 1 1 2 0.26 Malignant 6.3
6.3
6.3 neoplasm10.1
10.1
10.1(15.0%). 20.3
20.3
1
1
1
20.3
Hemangiopericytoma, malignant 9150 0 1 1 0.13 Between 2004 and 2008, primary brain tumors
Chordoma 9370 6 5 11 1.43 75.0included 295,986 cases–126,350 males 25.0and 169,636
25.0 30.0
Glioma, malignant 9380 3 5 8 1.04 75.0
75.0 25.0 30.0
30.0
females- across the US with a total incidence rate of 20.1
Ependymoma, NOS 9391 58 48 106 13.8
Ependymoma, anaplastic 9392 2 3 5 0.65 per 100,000
56.3-7.2 for
56.3 malignant and 12.9 for non-malignant
46.8
46.8
46.8 5
5
56.3 5
Papillary ependymoma 9393 4 2 6 0.78 tumors. The overall incidence is higher in females than
54.2
50.0
50.0males-21.34 versus18.32 per54.2 54.2
Astrocytoma, NOS 9400 44 25 69 9 50.0 100,000 31.3
persons (Ostrom
31.3
31.3 30.0
30.0
Astrocytoma, anaplastic 9401 6 6 12 1.56 30.0
and Barnholtz-Sloan, 2011; Dolecek et al., 2012). In
Fibrillary astrocytoma 9420 11 6 17 2.22
Pilocytic astrocytoma 9421 3 2 5 0.65 Saskatchewan, between 1970 to 2001, the incidence of
Pleomorphic xanthoastrocytoma 9424 0 1 1 0.13 25.025.0primary brain tumors was 11.1 per 100,000 persons: 12.5
25.0
Glioblastoma, NOS 9440 5 3 8 1.04 for males31.3
and 9.8 for
31.3
females (Pirouzmand
38.0
38.0
38.0 and Sadanand,
31.3
31.3 30.0 3
3
3
Oligodendroglioma, NOS 9450 1 1 2 0.26 31.3 31.3 30.0
30.0
2007). In registries of Australia 23.7from 2000 to 2008 the
23.7
23.7
Medulloblastoma, NOS 9470 0 1 1 0.13
Primitive neuroectodermal tumor overall incidence of primary brain tumors was 11.3 per
00
0
9473 6 2 8 1.04 100,000 person-years (Dobes et al., 2011).

None
Remission
recurrence
Ganglioneuroblastoma 9490 0 2 2 0.26 In a study between 1986-1993 in Spain the incidence

None
Remission
recurrence
treatment

treatment

None
Remission
orrecurrence
treatment

treatment
withouttreatment

Neuroblastoma, NOS 9500 3 7 10 1.3
Neuroepithelioma, NOS 9503 0 1 1 0.13
Meningioma, malignant 9530 3 0 3 0.39
Neurofibrosarcoma 9540 6 13 19 2.48
withtreatment
of primary brain tumors was 8.34 and 5.40 per 100,000
population of males and females, respectively (Lopez-
Abente et al., 2003). The incidence of primary brain
without

with

or
diagnosedwithout

diagnosedwith

Persistenceor
Neurilemmoma, malignant 9560 2 5 7 0.91 tumors in France (Bauchet et al., 2007). was 15.8 per
Persistence
Persistence
Malignant lymphoma
diagnosed

100,000. The French study shows 39.6% benign, 56.3%

Newlydiagnosed

NOS 9590 27 4 31 4.04

diagnosed
Newlydiagnosed

Non Hodgkin, NOS 9591 8 7 15 1.96 malignant and 4.1% unknown cases (Bauchet et al.,
Hodgkin disease, NOS 9650 5 2 7 0.91 2007). In the report of the cancer registry of Korea in
2005, the incidence of primary brain tumors was 11.69
Newly

Malignant lymphoma:
Newly

Small lymphocytic, NOS 9670 4 4 8 1.04

per 100,000 population (Lee et al., 2010). Manoharan
Newly
Newly

Small cleaved cell, diffuse 9672 2 0 2 0.26

100.0et al. (2012) reported primary brain tumors in Delhi
Mixed small & large cell, diffuse
9675 2 5 7 0.91 showing 6.3an incidence
10.1rate of 320.3
and 2 for males and females 1
Large B cell, diffuse, NOS 9680 15 10 25 3.26 per100,000, respectively (Manoharan et al., 2012).
Immunoblastic, NOS 9684 2 0 2 0.26
The worldwide incidence of primary25.0 malignant brain
Burkitt’s lymphoma, NOS 9687 2 0 2 0.26 75.0 30.0
Plasmacytoma, NOS 9731 17 7 24 3.13 tumors is reported as 3.7 for males and 2.6 for females per
Multiple myeloma 9732 0 1 1 0.13 100,000.56.3These rates
46.8 are higher in developed countries: 5
Total 429 338 767 5.8 and 4.1 in 100,000 males and females, respectively.
50.0Underdeveloped countries report 54.2
a lower incidence as 3
31.3 30.0
Table 9. Number and Relative Frequency (%) of Spinal and 2.1 per 100,000 cases in males and females (Bondy
Cord Tumors in Published Literature of Iran et al., 2008).
25.0 It seems that the reported incidence of brain tumors is
Rezaee et al. Ardehali* Total
related in part to the
31.3
38.0economy of various countries. The
31.3 3
30.0
Neurofibroma 23 (20.9) 44 (40.7) 67 (30.7) highest rates of incidence are 23.7seen in North America,
Meningioma 20 (18.2) 36 (33.3) 56 (25.7) Australia (Dobes et al., 2011), and Western Europe,
Ependymoma 12 (10.9) 10 (9.3) 22 (10.1) 0(Deltour et al., 2009) and the lowest incidences are
Astrocytoma 6 (5.5) 5 (4.6) 11 (5.0)
reported in Asia, Central and South American regions
None
Remission
Persistence or recurrence
Newly diagnosed without treatment

Newly diagnosed with treatment

Others 49 (44.5) 13 (12) 62 (28.4)

M:F 1.27 1.08 1.2
Total 110 108 218 (100)
*Metastasis and vertebral malignancies are excluded
Discussion
Based on systematic reviews, the incidence of primary
brain tumors in Iran is estimated to be 5.69 per 100,000;
Asian Pacific Journal of Cancer Prevention, Vol 14, 2013
(Ferlay et al., 2010). The GLOBOCAN 2008 study
published in 2010, estimated the highest incidence of
primary brain tumors in North Europe, and the lowest
incidence in Eastern Africa (Ferlay et al., 2010). The
incidence of brain tumors in Iran is lower than in
developed countries. Primary malignant brain tumors in
Iran are more common in males with a male to female
ratio of 1.48; the higher proportion of tumors in males
is in accordance with global distribution of tumors. In
3983
Seyed Behzad Jazayeri et al
our study all tumors except meningioma were diagnosed
more commonly in males, which is in compliance with the
worldwide distribution of primary brain tumors. However,
the incidence of primary brain tumors in the US (Dolecek
et al., 2012), Korea (Lee et al., 2010) and France (Baldi et
al., 2011) is more frequent in females. This might be due
to the higher rate of meningiomas (30.6% and 35%) and
lower rates for gliomas (17% and 30%) in Korea and US,
respectively. It might be noted that the broad category of
benign tumors is registered in the series from the US and
Korea, while benign tumors in Iran are estimated based
on available evidence.
Spinal cord tumors in Iran composed 7.1% of all CNS
tumors, while in the US spinal cord tumors form only
3% of all CNS tumors (Dolecek et al., 2012). The most
common pathologies for spinal cord tumors of US are
meningeal tumors, nerve sheath tumors and ependymoma.
(Dolecek et al., 2012).
Su et al. (1997) have reported the results of surgically
treated spinal cord tumors between 1988 and 1995 in
Taiwan. In their report of 117 patients, 69 were males
and 48 were females. The most common pathologies
were metastasis (45.3%), nerve sheath tumors (28.2%),
meningioma (12%), and neuroepithetial (6%) tumors.
Studies in Iran (Ardehali, 1990; Rezaee and Hadadian,
1997) have also reported the same common pathologies.
However, it should be noted that one third of primary
malignant spinal cord tumors are in malignant neoplasm
group of unknown pathology, some of which may be due
to radiologic diagnosis, non-operated or inoperable cases.
Nevertheless, in the US only 2.6% of spinal cord tumors
are in the unclassified neoplasm category (Dolecek et
al., 2012).
In the registry process many cases had failed to be
diagnosed pathologically due to early death, refusing
surgery, inappropriate tumor location for biopsy or
surgery, etc. These tumors are collectively accounted for
as malignant neoplasm in the registry system.
The main limitation of the NCR system is that benign
lesions are not registered. Although every effort was
made to select the best available data in analyzing benign
tumors, the single center or single author nature of these
studies may affect the overall analysis.
Meanwhile, metastasis is another interesting subject,
which we did not include in this study. The age distribution
of each tumor, especially in the pediatric age group will
be discussed in a separate paper.
To our knowledge, this report contains the most
recent incidence data for primary malignant CNS tumors
in Iran. Iranian NCR data have an average lag time of 4
years from data gathering to the final report, similar to
the CBTRUS program of the US (Dolecek et al., 2012).
Contrary to the CBTRUS program in the US, the Iranian
NCR does not register benign CNS tumors. Our study
emphasizes the need for separating within the CNS tumor
registry program both benign and malignant tumors. The
incidence of CNS tumors in Iran is in accordance with the
incidence of CNS tumors in developing countries. These
data estimate incidence of 2.74 malignant and 2.95 benign
lesions per 100,000 person-years, and a total of 5.69 per
100,000 person-years for primary brain tumors in Iran.
3984 Asian Pacific Journal of Cancer Prevention, Vol 14, 2013
Acknowledgements
We authors acknowledge Prof. Edward R. Laws,
Jr. (Department of Neurosurgery, Brigham & Women’s
Hospital) and Mrs. Bita Pourmand (Sina Hospital,
Research Development Center) for their careful editing.
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